Viewpoint
Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health
David R. Williams, PhD, MPHa SYNOPSIS Chiquita Collins, PhDb Racial residential segregation is a fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mecha- nism of racism that was de- signed to protect whites from social interaction with blacks. Despite the absence of support- ive legal statutes, the degree of residential segregation remains extremely high for most African Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differ- ences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates condi- tions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences. aDepartment of Sociology and Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI bDepartment of Sociology, University of Texas at Austin, Austin, TX Address correspondence to David R. Williams, PhD, MPH, Institute for Social Research, Univ. of Michigan, PO Box 1248, Ann Arbor, MI 48106-1248; tel. 734-936-0649; fax 734-647-6972; e-mail
404 ᭛ Public Health Reports / September–October 2001 /Volume 116 Racial Residential Segregation ᭛ 405
Racial disparities are large and pervasive across mul- cial inequalities in America.8–12 Segregation refers to tiple indicators of health status. Mortality data for the the physical separation of the races in residential con- United States reveal that, compared to the white popu- texts. It was imposed by legislation, supported by ma- lation, African Americans/blacks have an elevated jor economic institutions, enshrined in the housing death rate for 8 of the 10 leading causes of death.1 policies of the federal government, enforced by the Especially disconcerting is evidence revealing that judicial system, and legitimized by the ideology of white black-white disparities in health have not narrowed supremacy that was advocated by churches and other over time. For example, age-adjusted all-cause mortal- cultural institutions.11–13 These institutional policies ity for African Americans was one and a half times as combined with the efforts of vigilant neighborhood high as that of whites in 1998, identical to what it was organizations, discrimination on the part of real estate in 1950.1 Moreover, the black:white ratios of mortality agents and home sellers, and restrictive covenants to from coronary heart disease, cancer, diabetes, and cir- limit the housing options of black Americans to the rhosis of the liver were larger in the late 1990s than in least desirable residential areas. In both Northern and 1950.2 In the case of infant mortality, the black:white Southern cities, levels of black-white segregation in- ratio increased from 1.6 in 1950 to 2.4 in 1998.1 Such creased dramatically from 1860 to 1940 and have re- large and persistent racial disparities in health are mained strikingly stable since then.12 inconsistent with widely supported American values of The segregation of African Americans is distinctive. equality in society. Although most immigrant groups have experienced Healthy People 2010 is a major planning initiative some residential segregation in the United States, no of the United States government that seeks to elimi- immigrant group has ever lived under the high levels nate racial and ethnic disparities in health by the year of segregation that currently exist for the African 2010. The success of this initiative is contingent on American population.12 In the early 20th century, im- identifying and addressing the fundamental causes of migrant enclaves were never homogeneous to one these disparities. Researchers have long emphasized immigrant group. In most immigrant ghettos, the eth- the importance of distinguishing basic, fundamental nic immigrant group after which the enclave was causes from surface or proximate ones.3–7 Basic causes named did not constitute a majority of the population are those responsible for generating a particular out- of that area, and most members of European ethnic come. Changes in these factors produce corresponding groups did not live in immigrant enclaves.12,14 changes in outcomes. In contrast, although proximate The Civil Rights Act of 1968 made discrimination factors (surface causes) are related to outcomes, changes in the sale or rental of housing units illegal in the in these factors do not lead to changes in the relevant United States, but studies reveal that subtle and ex- outcomes. Accordingly, interventions to reduce or plicit discrimination in housing persists.15 Thus, al- eliminate racial disparities in health that focus only on though African Americans express higher support than proximate causes will have only limited effectiveness. members of other racial/ethnic groups for residence In this article, we argue that racial residential segre- in integrated neighborhoods,16 analyses of 2000 Cen- gation is the cornerstone on which black-white dis- sus data document that the residential exclusion of parities in health status have been built in the US. blacks remains high and distinctive.17 Nationally, the Segregation is a fundamental cause of differences in index of dissimilarity (a measure of segregation) for health status between African Americans and whites the United States declined from 0.70 in 1990 to 0.66 because it shapes socioeconomic conditions for blacks in 2000.17 An index of 0.66 means that 66% of blacks not only at the individual and household levels but would have to move to eliminate segregation.18 Gener- also at the neighborhood and community levels. We ally, a dissimilarity index value above 0.60 is thought to review evidence that suggests that segregation is a key represent extremely high segregation.19 In the 2000 determinant of racial differences in socioeconomic Census, more than 74 Metropolitan Statistical Areas mobility and, additionally, can create social and physi- (MSAs) were found to have dissimilarity scores greater cal risks in residential environments that adversely af- than 0.60.17 Instructively, these metropolitan areas con- fect health. tained the majority of the black population. In the last decade, segregation has declined the most in smaller, Nature and Origins of Residential Segregation growing cities, especially those of the Southwest and Although residential segregation is a neglected vari- West, and has remained relatively stable in the large able in contemporary discussions of racial disparities metropolitan areas of the Northeast and Midwest. The in health, it has long been identified as the central decline in segregation has been due to a reduction in determinant of the creation and perpetuation of ra- the number of all-white census tracts and has had no
Public Health Reports / September–October 2001 /Volume 116 406 ᭛ Viewpoint impact on very high percentage African American cen- tion per se, is the basic cause of the problems that sus tracts, the residential isolation of most African plague segregated schools. Compared to schools in Americans, or the concentration of urban poverty.17 middle-class areas, segregated schools have lower aver- age test scores, fewer students in advanced placement Segregation and Health Status: Individual and courses, more limited curricula, less qualified teach- Household SES ers, less access to serious academic counseling, fewer Researchers have identified socioeconomic status (SES) connections with colleges and employers, more dete- as a fundamental cause of the observed social inequali- riorated buildings, higher levels of teen pregnancy, ties in health4–6 and in particular of racial differences and higher dropout rates.21 These conditions contrib- in health.7 Yet health researchers and practitioners ute to peer pressure against academic achievement have given inadequate attention to the causes of racial and in support of crime and substance use. Black and disparities in SES. Racial differences in SES are the Latina/o students are concentrated in urban schools predictable results of the successful implementation that have different and inferior courses and lower of institutional policies and arrangements, with resi- levels of achievement than the schools attended by dential segregation being a prominent one in the US white students in adjacent suburban school districts. context. By determining access to educational and Thus, racial residential segregation leads to racial dif- employment opportunities for African Americans, resi- ferences in high school dropout and graduation rates; dential segregation has truncated their socioeconomic competencies and knowledge of high school gradu- mobility and has been a central mechanism by which ates; preparation for higher education; and the prob- racial inequality has been created and reinforced in ability of enrollment in college. the United States.12,13 Segregation and Employment Opportunities Segregation and Educational Opportunity Second, institutional discrimination, based on residen- First, residential segregation has led to highly segre- tial segregation, severely restricts employment oppor- gated elementary and high schools and is a funda- tunities, and thus income levels, for African Ameri- mental cause of racial differences in the quality of cans. In the last several decades there has been a mass education. For most Americans, residence determines movement to the suburbs of low-skilled, high-paying which public school students can attend, and the fund- jobs from many of the urban areas where blacks are ing of public education is under the control of local concentrated.22,25,26 This has created a “spatial mis- government. Thus, community resources importantly match” in which African Americans reside in areas determine the quality of neighborhood schools. There that do not offer ready access to high-paying entry- is a very strong relationship between residential segre- level jobs. It has also led to a “skills mismatch” in gation and the concentration of poverty. Public schools which the available jobs in the urban areas where with high proportions of blacks and Hispanics are African Americans live require levels of skill and train- dominated by poor children.21 Nationally, the correla- ing that many do not have. Some corporations explic- tion between the percentage of poor students in a itly use the racial composition of areas in their deci- school and the percentage of black and Hispanic stu- sion-making processes regarding the placement of new dents was 0.66 in 1991.20 In metropolitan Chicago, the facilities and the relocation of existing ones.27 Nega- correlation between the percentages of poor and non- tive racial stereotypes of African Americans and the white students was 0.90 for elementary schools in areas where they are concentrated play an important 1989.21 Although there are millions of poor whites in role in many of these decisions.28,29 Thus, during rou- the US, poor white families tend to be dispersed tine “non-racial” restructuring, relocation, and throughout communities, with many residing in desir- downsizing, employment facilities are systematically able residential areas.21,22 In 96% of predominantly moved to suburban and rural areas where the propor- white schools, the majority of students come from tions of African Americans in the labor force are low. middle-class backgrounds.21 For example, a Wall Street Journal analysis of more than Levels of segregation for black and Latina/o stu- 35,000 US companies found that African Americans dents are currently on the increase.23 One recent study were the only racial group that experienced a net job found that as a growing number of minority families loss during the economic downturn of 1990–1991.30 moved to the suburbs from 1987 to 1995, residential African Americans had a net job loss of 59,000 jobs, segregation there led to increased levels of segrega- while there was a net gain of 71,100 for whites, 55,100 tion in suburban schools.24 for Asians, and 60,000 for Latina/o/s. The concentration of poverty, not racial composi- Residential segregation also affects employment
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opportunities by isolating blacks in segregated com- Households of black women who completed high munities from both role models of stable employment school earned 64 cents for every dollar earned by and social networks that could provide leads about comparable white households, and households of black potential jobs.22 The social isolation created by these women with a college degree earned 74 cents for ev- structural conditions in segregated residential envi- ery dollar earned by comparable white households. ronments can then induce cultural responses that The largest racial difference evident in Table 1 is weaken the commitment to norms and values that for wealth. The median net worth of whites is almost may be critical for economic mobility. For example, six times that of blacks. This underscores the extent to long-term exposure to conditions of concentrated which racial differences in income understate racial poverty can undermine a strong work ethic, devalue differences in economic status and resources. At every academic success, and remove the social stigma of level of income, blacks have considerably less wealth imprisonment as well as of educational and economic than whites.36 For example, the net worth at the lowest failure.31 quintile of income is $9,720 for white households, compared to $1,500 for African American households Consequences of Segregation: Racial Differences (Table 1). At the highest quintile of income, white in SES households have a net worth of $123,781, compared After a thorough empirical analysis of the effects of to $40,866 for black households. Racial differences in segregation on young African Americans making the wealth also link the current situation of blacks to his- transition from school to work, Cutler et al. concluded toric processes of segregation. For most American fami- that the elimination of residential segregation would lies, housing equity is a major source of wealth. Thus, lead to the disappearance of black-white differences today’s black-white differences in wealth are, to a con- in earnings, high school graduation rates, and idle- siderable degree, a direct result of the institutional ness and would reduce racial differences in single discrimination in housing practiced in the past that motherhood by two-thirds.32 Segregation is thus a cen- limited the home ownership opportunities of blacks.37 tral force in producing the large racial differences in However, racial differences in housing equity also socioeconomic circumstances evident in Table 1. In reflect contemporary segregation because African 1998, whites had higher levels of income and educa- Americans tend to receive smaller returns on their tion attainment and lower levels of poverty and unem- investment in a home than whites. The growth in ployment than African Americans. Other data reveal housing equity over time is smaller for black home- that large racial differences in unemployment persist owners in highly segregated areas than for owners of even at equivalent levels of education.33 comparable homes in other areas.37 Many socioeconomic indicators are not equivalent across race.34,35 For example, a given level of education Race, SES, and Health may not reflect the same degree of educational prepa- SES accounts for much of the racial differences in ration and skills. There are also racial differences in health, yet it is frequently found that SES differences the income returns for a given level of education, with within each racial group are substantially larger than blacks, especially black males, earning less income than overall racial differences.2,38,39 Table 2 illustrates the whites at comparable levels of education (Table 1). In key role that SES plays in racial/ethnic differences in addition, American women of all racial groups earn health with national data on activity limitation and less than their similarly educated male counterparts. self-rated health. The rate of activity limitation due to This gender difference in earnings combined with chronic conditions is higher for blacks than for whites, racial differences in household structure (black house- and blacks are more likely to report being in fair or holds are more likely than white ones to be headed by poor health than whites. When stratified by economic a female33), means that, especially for women, racial status, the rates of activity limitation are almost identi- differences in individual earnings at equivalent levels cal for blacks and whites, suggesting that the higher of education, understate racial differences in house- prevalence of low income among African Americans hold income. National data, as shown in Table 1, indi- completely accounts for the observed black-white dif- cates that in 1996, black households in which the sur- ference on this outcome. vey respondent was a college-educated male earned 80 The black-white pattern for self-rated health reflects cents for every dollar earned by a comparable white the more familiar pattern in which income predicts household. Such racial differences in the returns to variation in health for both groups but blacks report education are evident at all levels of educational prepa- poorer health than whites at all levels of income. Such ration but are more marked for women than for men. a pattern exists for other health outcomes, such as
Public Health Reports / September–October 2001 /Volume 116 408 ᭛ Viewpoint
Table 1. Selected socioeconomic indicators for black and white populations, United States, 1998
Indicator Black White Median household income $25,351 $40,912 Poverty indicators Percent of population below poverty level 26.1 10.5 Percent of children <18 years old below poverty level 36.4 14.4 Percent of people Ն65 years old below poverty level 26.4 8.9 Educational attainment of those age 25 years and older High school graduate or higher (percent) 76.0 83.7 College graduate or higher (percent) 14.7 25.0 Percent of population Ն16 years old unemployed 8.9 3.9 Personal income by education, ages 25–64 years Median income, high school graduate, male $22,099 $29,789 Median income, college graduate, male $39,278 $53,158 Median income, high school graduate, female $14,355 $15,733 Median income, college graduate, female $33,865 $31,454 Household income by education of survey respondent Ն25 years old, 199640 Median income, high school graduate, male $36,020 $41,200 Median income, college graduate, male $54,500 $67,952 Median income, high school graduate, female $23,556 $37,000 Median income, college graduate, female $47,100 $64,007 Wealth (1995)36 Median net worth $ 7,073 $49,030 Median net worth, lowest income quintile $ 1,500 $ 9,720 Median net worth, highest income quintile $40,866 $123,781 NOTE: Data are for 1998, except as noted. Source of data is Reference 112, except as noted.
coronary heart disease mortality and life expectancy.40 can households earned 59 cents in income for every The residual effect of race, after SES is controlled for, dollar earned by whites, and African Americans had a could reflect the non-equivalence of individual indica- poverty rate that was 2.5 times as high and an unem- tors of SES across race, racial differences in commu- ployment rate that was twice as high as whites. nity context, the long-term consequences of exposure Analysis of economic and health data for the last 50 to adversity in childhood, and the effect of other as- years reveals that the narrowing of the black-white gap pects of racism. Two studies have reported that per- in economic status was associated with a parallel nar- ceptions of discrimination make an incremental con- rowing of the black-white gap in health; similarly, a tribution to explaining racial differences in self-rated widening of the racial gap in SES was associated with a health after SES is accounted for.41,42 widening gap in health.44 Specifically, during the late In the United States, large and persistent black- 1960s and the mid-1970s, as a result of the gains of the white differences in health co-occur with large and Civil Rights Movement, there was some narrowing of persistent black-white differences in SES. The Economic the black-white gap in income.43 There was a corre- Report of the President in 1998 documented that there sponding narrowing of the racial gap in health status. was little change in the economic gap between blacks That is, from 1968 to 1978, across multiple causes of and whites in the last quarter of the 20th century.43 In death, black men and women experienced a larger 1978, black households earned 59 cents for every dol- decline in mortality, both on a percentage and an lar earned by white households, and had a poverty absolute basis, than their white counterparts.45 Life rate that was 3.5 times as high and an unemployment expectancy data for this period show larger gains for rate that was 1.9 times as high. In 1996, African Ameri- blacks than whites on both a relative and an absolute
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Table 2. Percentage of individuals reporting fair or poor health and activity limitations, by black vs white race and by household income, United States, 1997
Percent reporting activity limitations Percent reporting fair or poor health
Household income Black White Black White Poor 29.4 29.5 25.6 20.6 Near poor 20.0 20.7 19.5 14.1 Non-poor 10.7 10.7 9.6 5.7 Total 17.0 13.2 15.8 8.0 SOURCE OF DATA: Reference 1
basis. During the early 1980s, in the wake of substan- and behavioral risk factors for coronary heart disease tial changes in social and economic policies at the (smoking, exercise, hypertension, diabetes, obesity, and national level, the health status of economically vul- LDL and HDL cholesterol), people residing in disad- nerable populations worsened in several states.46,47 Simi- vantaged neighborhoods had a higher incidence of larly, the black-white gap in health status widened be- heart disease than people who lived in more advan- tween 1980 and 1991 for multiple health outcomes, taged neighborhoods.52 Several studies have specifically including life expectancy, excess deaths, and infant operationalized residential segregation and related the mortality.35,48 level of segregation to rates of morbidity and mortal- ity. This body of research has found that residential Segregation and the Effects of Place segregation is related to elevated risks of cause-specific Segregation can also adversely affect health by creat- and overall adult mortality,53–56 infant mortality,57–60 and ing a broad range of pathogenic residential condi- tuberculosis.61 On the other hand, one study found tions that can induce adverse effects on health status. that the degree of residential segregation was unre- Measures of segregation appear to capture some of lated to infant mortality rates.62 There are multiple the effects of racism at the area level, and these com- characteristics of low SES environments, in general, munity-level effects are one reason for the persistence and segregated environments, in particular, that are of racial differences in health status even after con- likely to be related to health. We now consider some trols are introduced for individual variations in SES.49 of the ways in which residence in segregated areas can The available evidence clearly indicates that racial seg- adversely affect health. Because of the paucity of work regation has created distinctive ecological environ- in this area, we include a discussion of the related ments for African Americans. For example, although work of Sally Macintyre and colleagues from Scotland numerically there are more poor whites than poor that illustrates area variations in risk factors for disease. African Americans in the US, most poor white people are residentially located next to non-poor people, while Segregation and Neighborhood and Housing Quality most poor African Americans are concentrated in high- Residential segregation can lead to large differences poverty neighborhoods.22 An analysis of the 171 larg- in neighborhood quality. Racial residential segrega- est cities in the US indicated that there was not even tion has also led to unequal access for most blacks to a one city where whites lived in comparable ecological broad range of services provided by municipal au- conditions to blacks in terms of poverty rates and thorities. Political leaders have been more likely to cut single-parent households.50 Sampson and Wilson con- spending and services in poor neighborhoods, in gen- cluded, “The worst urban context in which whites re- eral, and African American neighborhoods, in par- side is considerably better than the average context of ticular, than in more affluent areas.31,63,64 Poor people black communities.”50 and members of minority groups are less active politi- A growing number of studies using multilevel analy- cally than their more economically and socially ses indicate that social and economic characteristics of advantaged peers, and elected officials are less likely residential areas are associated with a broad range of to encounter vigorous opposition when services are health outcomes independent of individual indicators reduced in the areas in which large numbers of poor of SES.51 For example, Diez Roux and colleagues found people and people of color live. This disinvestment of that even after adjustment for education, income, and economic resources in these neighborhoods has led occupational status and a broad range of biomedical to a decline in the urban infrastructure, physical envi-
Public Health Reports / September–October 2001 /Volume 116 410 ᭛ Viewpoint ronment, and quality of life in these communities.65,66 regulate temperature and humidity, as well as elevated The selective out-migration of many whites and some exposure to noxious pollutants and allergens (includ- middle-class blacks from cities to the suburbs has also ing lead, smog, particulates, and dust mites) are all reduced the urban tax base and the ability of some common in poor, segregated communities.66,71 These cities to provide a broad range of supportive social aspects of the physical environment have been shown services to economically deprived residential areas.31 to adversely affect health.71,72 Racial differences in neighborhood quality persist at all levels of SES. Middle-class suburban African Segregation and Health Behaviors Americans reside in neighborhoods that are less seg- Research also reveals that the socioeconomic charac- regated than those of poor, central city blacks.67 How- teristics and segregation levels of particular areas can ever, compared to their white counterparts, middle- lead to dramatic variations in factors conducive to the class blacks are more likely to live in poorer quality practice of healthy or unhealthy behaviors. In Glasgow, neighborhoods with white neighbors who are less there were more athletic tracks, playing fields, and affluent than they are.67 That is, middle-class blacks swimming pools in economically advantaged neigh- are less able than their white counterparts to translate borhoods than in economically disadvantaged ones.69 their higher economic status into desirable residential US research also reveals that a lack of recreational conditions. One recent analysis of 1990 Census data facilities and concerns about personal safety can dis- revealed that suburban residence does not buy better courage leisure time physical exercise. For example, housing conditions for blacks.68 The suburban loca- analysis of data from the 1996 Behavioral Risk Factor tions where African Americans reside tend to be equiva- surveys for five states found a positive association be- lent or inferior to those of central cities.68 tween the perception of neighborhood safety and physi- Research by Macintyre and colleagues in four neigh- cal exercise.73 Instructively, this association was some- borhoods of Glasgow, Scotland, that varied in eco- what larger among members of racial/ethnic minority nomic characteristics illustrates the ways in which neigh- groups than among whites. borhood areas can vary in the provision of resources Segregation can also lead to racial differences in that support health.69,70 These researchers found that the purchasing power of a given level of income for a neighborhood areas differed in terms of access to pub- broad range of services, including those that are nec- lic and private transportation, exposure to personal essary to support good health. Many commercial en- and property crime, amenities, neighborliness, and terprises avoid segregated urban areas; as a result, the problems such as litter, noxious odors, and discarded available services are typically fewer in quantity, poorer needles. US research has found that poor, segregated in quality, and often higher in price than those avail- African American neighborhoods are also character- able in less segregated urban and suburban areas. On ized by high mobility, low occupancy rates, high levels average, blacks pay higher costs than whites for hous- of abandoned buildings and grounds, relatively larger ing, food, insurance, and other services.35 The con- numbers of commercial and industrial facilities, and sumption of nutritious food items is positively associ- inadequate municipal services and amenities, includ- ated with their availability, and the availability of ing police and fire protection.71 Neighborhood prob- healthful products in grocery stores varies across coun- lems are associated with ill health. For example, Collins ties as well as ZIP Codes.74 Thus, the high cost and and colleagues found a positive association between a poor quality of grocery items in segregated neighbor- woman’s negative rating of her neighborhood (in terms hoods can lead to poorer nutrition. of police protection, municipal services, cleanliness, Researchers have long noted that both the tobacco quietness, and schools) and the likelihood of having a and alcohol industries have heavily targeted poor mi- low birthweight infant.49 nority communities with advertising for their prod- The quality of housing is also likely to be poorer in ucts.75–79 These marketing strategies include greater highly segregated areas, and poor housing conditions intensity of large highway billboard advertising in mi- can also adversely affect health. Multiple housing stres- nority communities, the increasing use of smaller but sors (dampness or condensation, inadequate heat, more visible billboards, the concentration of alcohol problems with noise and vibration from outside, the and tobacco ads in print outlets with large minority lack of space and the lack of private space, as well as readerships, and the increasing level of corporate spon- the presence of environmental hazards) varied by area sorship of athletic, cultural, civic, and entertainment in the four contrasting neighborhoods in Glasgow, events targeted to minority consumers.79 Moreover, Scotland.72 Similarly, US data indicate that crowding, tobacco and alcohol use are coping strategies that are substandard housing, elevated noise levels, inability to frequently employed to obtain escape and relief from
Public Health Reports / September–October 2001 /Volume 116 Racial Residential Segregation ᭛ 411 the personal suffering and deprivation that character- on negative stereotypes of race and residence plays a izes many disadvantaged environments. Many segre- role.91,92 gated areas have high levels of multiple sources of stress, including violence, financial stress, family sepa- Segregation and Crime, Homicide, and ration, chronic illness, death, and family turmoil.71 Social Context Research reveals that exposure to stress is positively An investigation of segregation also sheds light on the associated with tobacco, alcohol, and drug use.80–83 racial differences in some health outcomes that have One recent study of African Americans in 10 different strong environmental components. African Americans census tracts in Southern California found a positive are much more likely than whites to be victims of all association between cigarette smoking and a measure types of crime, including homicide.33 Of the 15 lead- of lifetime exposure to segregation.84 ing causes of death in the United States, the black- Data from Scotland have documented an area ef- white gap is largest for homicide. In 1996, the death fect on the practice of a broad range of health behav- rate from homicide for African Americans was 30.6 iors, independent of individual characteristics.85 That per 100,000 population—virtually identical to the rate is, even after adjustment for age, gender, and indi- of 30.5 in 1950.1 Several studies have found that segre- vidual indicators of SES, the data show that people gation is positively associated with the risk of being a living in more economically deprived neighborhoods victim of homicide for blacks,31,93–96 although this were more likely to smoke, less likely to consume finding is not uniform.97 Table 3 presents the homi- healthy foods (such as fruits, vegetables, and whole cide rates for men and women for 1994–1995 stratified grain bread), more likely to consume unhealthy foods by self-reported race and education. Irrespective of (such as sweets, cakes, processed meats, and french racial status, the homicide rate was strongly patterned fries), and less likely to exercise than their counter- by SES. For both men and women, the racial gaps parts in wealthier neighborhoods.85 Not surprisingly, were large even at identical levels of education, with, residents of more economically deprived neighbor- for example, the homicide rate of black males in the hoods were shorter, had higher body mass indexes, highest education category exceeding that of white larger waist circumferences, and higher waist-hip ra- males in the lowest education group. These dramatic tios than their peers in more economically advantaged racial differences may reflect an important area effect. residential areas.86 Sampson’s research on the causes of urban vio- lence clearly suggests that the elevated homicide rate Segregation and Medical Care of African Americans is a consequence of residential Segregation is also likely to adversely affect access to segregation.98 His research indicates that in black ur- high quality medical care. The four Glasgow neigh- ban communities characterized by high rates of pov- borhoods varied in the quality of primary health care erty, there are only very small pools of employable or services (health clinics, physicians, dentists, opticians, stably employed males. Social science research has and pharmacies).69 African Americans face challenges long documented that high male unemployment and in accessing medical care, and it is likely that these low wage rates for males are associated with higher are more acute in segregated areas. Health care fa- rates of female-headed households for both blacks cilities are more likely to close in poor and minority and whites.99 Lack of access to jobs produces high communities than in other areas.87,88 One recent study rates of male unemployment and underemployment, of New York City neighborhoods revealed that phar- which in turn underlies the high rates of out-of-wed- macies in minority neighborhoods were less likely lock births, the large numbers of female-headed house- than pharmacies in other areas to have adequate holds, the “feminization of poverty,” and the extreme medication in stock to treat people with severe pain.89 concentration of poverty in many black communi- Moreover, other recent research documents that, ir- ties.100,101 In turn, single-parent households lead to lower respective of residence, African American and mem- levels of social control and supervision. Sampson docu- bers of other minority groups are less likely than mented a strong association between family structure whites to receive appropriate medical treatment after and violent crime.98 Importantly, the relationship be- they gain access to medical care.90 This pattern exists tween family structure and violent crime for whites across a broad range of medical procedures and in- was identical in sign and magnitude to that for blacks. stitutional contexts and is not accounted for by dif- Thus, the elevated rates of violent crime and homicide ferences in SES, insurance, or disease severity. The for African Americans are determined by the struc- causes of these disparities have not been identified, tural conditions of their residential contexts. Relatedly, but it is likely that unconscious discrimination based residential segregation also contributes to racial dif-
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Table 3. Homicide rates among adults 25–44 years of age by educational attainment, sex, and black vs white race, 1994–1995
Male Female
Household income Black White Black White <12 years 163.3 25.0 38.2 10.2 12 years 110.7 10.6 22.0 4.7 Ն13 32.4 2.9 9.4 1.6 Total (1995)1 77.9 11.0 17.4 3.3 SOURCE OF DATA: Reference 40 for all data except 1995 totals
ferences in drug use. A study using national data re- unskilled individuals with low levels of educational vealed that elevated rates of cocaine use by blacks and attainment.105 The lower levels of segregation for most Hispanics in individual-level data could be completely Hispanic groups suggest that the long-term socioeco- explained when individuals were grouped into neigh- nomic trajectory of Hispanics is likely to be somewhat borhood clusters based on Census characteristics.102 better than that of African Americans.106 On the other hand, the Hispanic population faces considerable Research Directions difficulties with socioeconomic mobility due to sub- This article has focused heavily on the experience of stantial barriers to occupational mobility and persist- African Americans. Research is needed to explore the ing educational disadvantages.105 The situation of His- extent to which segregation affects the health of other panics highlights the heterogeneity of minority minority populations and to identify the fundamental populations and the importance of paying attention causes of all racial/ethnic disparities in health. Similar to the specific circumstances of each population group. to the pattern for African Americans, long-term data The consequence of segregation for whites is an- for American Indians served by the Indian Health other issue worthy of careful empirical scrutiny. One Service indicate widening American Indian-white dis- recent study found that segregation was associated parities for multiple causes of death.103 For example, with elevated mortality for whites in cities high on two the American Indian mortality rate for diabetes was indices of segregation.54 However, it is not clear whether 1.3 times as high as that of whites in 1955, but 3.7 this reflects an adverse effect of some of the structural times as high in 1993. Similarly, the American characteristics of highly segregated cities or a selec- Indian:white mortality ratio for liver cirrhosis increased tion effect in which more vulnerable whites (in terms from 2.9 in 1955 to 4.6 in 1993. Reservations are an- of SES, age, and health) did not migrate out of highly other prominent example of residential segregation segregated cities. that deserves careful examination in identifying the Finally, research is needed to catalogue and quantify basic causes of health challenges faced by many Ameri- the specific aspects of the social and physical environ- can Indians and Alaskan Natives. ments of segregated neighborhoods that are plausibly Segregation is a factor that may also adversely affect linked to health. The assessment strategies that have Hispanics, although its impact on the Hispanic popu- been used in Chicago107 and Glasgow70 are good places lation is likely to be smaller than that for African to start. However, such approaches must be expanded Americans. Levels of segregation of Hispanics from to capture potentially health-enhancing aspects of resi- whites are moderate, compared to those of African dence in segregated areas. Mental health researchers Americans.104 Even under conditions of high immigra- have long documented that mental health is enhanced tion, there has not been the expected large increase when group members reside in enclaves with higher in residential segregation for Hispanics in recent de- concentrations of their group.108–110 The conditions cades.104 Mainland Puerto Ricans are the exception to under which segregation can positively and negatively this generalization. Because of their relatively higher affect health are not well understood. Additionally, theo- level of African ancestry, Puerto Ricans are distinctive retically driven multilevel analytic models are needed among Hispanic groups in having high levels of segre- that will identify how characteristics of the physical and gation.104 More important than segregation as a deter- social environment relate to each other and combine minant of the low SES levels of other Hispanic sub- with individual predispositions and characteristics in groups is the immigration of large numbers of relatively additive and interactive ways to influence health.
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CONCLUSION tion and the making of the underclass. Cambridge (MA): Harvard University Press; 1993. It is widely recognized that a pervasive and persistent 13. Jaynes GD, Williams RM. A common destiny: blacks pattern of racial disparities across a broad range of and American society. Washington: National Academy indicators of health status is determined by a complex, Press; 1989. multifactorial web of causation. One effective way to 14. Lieberson S. A piece of the pie: black and white immi- eliminate these disparities is to identify and eliminate grants since 1880. Berkeley: University of California the “spiders” responsible for creating the web in the Press; 1980. first place.111 The evidence reviewed suggests that ra- 15. Fix M, Struyk RJ. Clear and convincing evidence: mea- cial residential segregation, an institutional manifesta- surement of discrimination in America. Washington: tion of racism, is one of the most important “spiders” Urban Institute Press; 1993. 16. Bobo L, Zubrinsky CL. Attitudes on residential integra- responsible for persisting black-white inequalities in tion: perceived status differences, mere in-group pref- health. Inattention to eliminating residential segrega- erence, or racial prejudice? Soc Forces 1996;74:883- tion and/or the conditions created by it may limit the 909. utility of well-intentioned efforts to reduce racial dis- 17. Glaeser EL, Vigdor JL. Racial segregation in the 2000 parities in health. Thus, effective efforts to reduce Census: promising news. Brookings Institution Survey racial disparities in health status should seriously Series. Washington: Brookings Institution; 2001. grapple with reducing racial disparities in socioeco- 18. Massey DS, Denton N. The dimensions of residential nomic circumstances, and with targeting interventions segregation. Soc Forces 1988;67:281-315. not only at individuals but also at the geographic con- 19. Massey DS, Denton NA. 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